Primary percutaneous coronary intervention (PCI) is the cornerstone of treatment in patients with acute ST-segment elevation myocardial infarction (STEMI).1 Over the last decades, European countries have tried to structure their health care systems so that almost every patient with STEMI has access to primary PCI.2 This means that local networks, including ambulance systems, hospitals without a catheterization laboratory, and hospitals with 24-hour PCI facilities have to be organized to maintain a high level of care. A crucial point is to ensure sufficient hospital and PCI capacities so that all patients with STEMI can undergo primary PCI within 2 hours after the diagnostic electrocardiogram.3

Problems can occur in the case of natural disasters, pandemics, or conflicts such as wars between countries. One such example is the war in Ukraine, which could be affecting the Polish health care system in 2 ways: refugees who permanently live in Poland and Ukrainian citizens who live near the border with Poland, and who do not have access to regular health care because of war-related problems in Ukrainian hospitals. The estimated number of refugees living mostly in Polish cities near the border is above 1 500 000. This means that in these cities up to 30% of the population consists of refugees. Certainly, these refugees are under increased stress due to the situation in their country, which might make them susceptible to a higher risk for acute coronary events.

The study by Mamas et al,4 published in this issue of Polish Archives of Internal Medicine, investigated the influence of the war in Ukraine on STEMI care in Poland. The authors found that in PCI centers localized below 100 km from the border the number of primary PCIs increased by 15 procedures per month, which means 1 additional primary PCI every other day. Baseline characteristics of STEMI patients were comparable before and during the war. Interestingly, direct transport to a PCI center was observed more often during the war time (41% vs 22%). In hospitals below 100 km from the border, the procedural fatality rate increased from 1.22% before the war to 3.25% during the war; however, this increase was not statistically significant (adjusted odds ratio, 2.24; 95% CI, 0.78–6.48), most likely due to the low number of patients included during the war. Unfortunately, an important information being a measure of quality of care has not been reported, which is the door-to-balloon time. It is stated that pain-to-balloon time was not different before and during the war, but the actual times are not given. To have an idea about the impact of the war on outcomes, 30-day or 1-year mortality data would be helpful.

The results suggest that the war in Ukraine had none or only little impact on STEMI care in Poland. The slight increase in the number of patients treated per month did not limit the capacities of Polish catheterization laboratories to maintain their high level of STEMI care. This is reassuring, because even in war times coronary artery disease remains the leading cause of death in the European countries. Other examples of challenges to the health care systems include the COVID-19 pandemic, the climate change, and natural disasters, such as earthquakes. There were conflicting reports about the influence of the COVID-19 pandemic on the incidence and outcomes of acute MI in the European countries. The absolute impact of the COVID-19 pandemic on mortality in patients with acute coronary syndrome (ACS) must be divided into 2 populations, the first dying at home or before hospital admission, and the second admitted to the hospital and dying after the admission. In the Spanish International Study on Acute Coronary Syndromes-STEMI COVID-19 registry,5 where a total of 6609 STEMI patients were analyzed and compared with patients treated before the pandemic outbreak, there was a significant reduction in the number of primary PCI procedures during the pandemic (in 2020), as compared with 2019, especially for patients with arterial hypertension. In addition, a higher mortality rate was observed during the first wave of the COVID-19 pandemic. There have been similar reports from other countries, such as Italy and the United Kingdom.6,7 The reasons for the reported higher mortalities might be different, depending on the region, health care systems, and in some reports on chance due to a small sample size. Based on the overall COVID-19 infection rate, some regions allocated all resources to the care for COVID-19 patients, leading to a lower use of primary PCI and thus higher mortality. These observations on mortality could not be confirmed by a representative sample size from German hospitals. In these hospitals, revascularization procedures and in-hospital mortality did not differ between 2018, 2019, and 2020, both in non-STEMI and STEMI patients.8 This might be due to the fact that German hospitals were still able to adequately care for ACS patients in 2020, and had not reached their limit of capacity due to the care for COVID-19 patients. In the Polish experience during the war in Ukraine, a decline in PCI numbers was not observed, so it is unlikely that more people died at home. Nevertheless, precautions should be undertaken to maintain STEMI care in such situations where hospital or personal resources might be limited. A temporal 15% increase seems not to affect STEMI care in well-organized systems.